SESSION TITLE: Infectious Disease Global Case Reports
SESSION TYPE: Global Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Diffuse parenchymal lung disease is commonly encountered in pulmonary medicine practice. Multiple etiological factors need to be considered. One such intersting case is presented.
CASE PRESENTATION: A 35 years old farmer presented with a history of fever, breathlessness, headache and cough since 25 days. His symptoms developed four days after descending into an abandoned well that was to be cleaned. They were gradually progressive in nature. There was no history of chest pain or hemoptysis. He was a non-smoker; there were no addictions except occasional tobacco chewing. He had been administered anti-TB treatment by his local healthcare provider. There was no clinical or radiological improvement following which he was referred to this center. On physical examination, he was conscious and oriented. His pulse rate was 100/min, respiratory rate was 36/min and abdomino-thoracic, BP was 140/90 mmHg. Respiratory system examination showed tachypnea, and fine inspiratory crackles bilaterally The cardiovascular and abdomen examination was normal. Further investigations revealed Hb 15.9 g%, TLC 14000/cu mm, DLC P67 L30 M1 E2, ESR 18, platelets 2,68.000/cu mm, urinalysis was normal, HIV ELISA was negative; urea 29 mg/dL, creatinine 0.8 mg/dL Na 135 meq/L, K 5.1 meq/L, bilirubin 0.9 mg/dL, SGOT 45, SGPT 62, alkaline phosphatase 72, protein 7.1 g/dL, albumin 3.5 g/dL, and globulin 3.6 g/dL . Arterial bood gas analysis (on FiO2 0.21) was PaO2 60.8 mmHg, PaCO2 mmHg, pH 7.434, HCO3a 19.9 meq/L, HCO3s 22.8 meq/L, SaO2 92.4 %. The chest X-ray and CT thorax were suggestive of military nodules distributed diffusely, bilaterally. A diagnostic bronchoscopy procedure was performed. Bronchial washings revealed no pus cells, no organisms; aerobic culture was sterile; no AFB was seen; smear examination revealed benign epithelial cells. CSF examination was within normal limits. Serum sample for Cryptococcus antigen was negative. Trans-bronchial lung biopsy revealed pulmonary cryptococcosis. Final Diagnosis Isolated pulmonary cryptococcosis with acute lung injury He was treated with Inj Amphotericin B 0.7mg/kg/day IV for 4 weeks. This was followed by fluconazole 400 mg/day. Oxygen therapy and supportive care were provided.The patient recovered completely. His follow up spirometry and arterial blood gas analysis were within normal limits.
DISCUSSION: Cryptococcus neoformans is a yeastlike fungus which reproduces by budding and forms round yeastlike cells. Weathered pigeon droppings commonly contain serotype A or D (C.neoformans var. neoformans). C.neoformans has been isolated from the litter around trees of the specimen Eucalyptus camaldulensis and E. tereticornis. Infection is acquired by inhalation of the fungus. Pulmonary infection has a tendency toward spontaneous resolution and is frequently asymptomatic. Silent hematogenous spread may occur to perivascular areas of gray matter in basal ganglia. Lung lesion is characterised by intense granulomatous inflammation. Tissues are stained with methenamine silver, periodic acid-Schiff and mucicarmine. Most patients have meningoencephalitis at the time of diagnosis which results in death within 2 to several years after onset if left untreated. Chest pain oocurs in 40% and cough in 20% cases. Fever is modest or absent. X-ray shows one or more dense infiltrates which are often well circumscribed. Cavitation, pleural effusion and hilar adenopathy are infrequent. Calcification and fibrotic stranding are rare. Pulmonary cryptococcosis appears on CT as nodules with smooth or relatively undefined margins and homogeneous attenuation. Sputum culture is positive in only 10% Serum antigen test is positive in only 1/3cases. Biopsy is usually required Treatment consists of amphotericin B (0.6-0.7 mg/kg daily) or liposomal AmB (4-5 mg/kg daily) for 2 weeks and until symptoms improve; then fluconazole (400 mg/day) for 8 weeks; alternatively itraconazole (400 mg/day) for 8 weeks after AmB; then 200 mg/day maintenance.
CONCLUSIONS: A case of isolated pulmonary cryptococcosis with acute lung injury in a immuno-competent host contracted by an acute exposure to the pathogen is reported.
Reference #1: Saag MS, Graybill RJ, Larsen RA et al: Clin Infect Dis 2000;30:710
Reference #2: Nadrous HF, Antonios VS, Terrell CL, Ryu JH. Chest. 2003;124:2143-2147
Reference #3: Núñez M, Peacock J, and Chin R. Chest 2000;118:527-534.
DISCLOSURE: The following authors have nothing to disclose: Manas Sen
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